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Safety a d Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System! <br /> 201 E.Washington Ave. <br /> In accord with ILHR 63 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary�mi Number <br /> The information you provide may be used by other government agency programs El Check if revlslon�pFewous alp/•Jp'ii[a/frion <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number�/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION / ' <br /> Property Owner Name Property Location <br /> JE EMrL 1/4 1/4,S 7 T 110 N, R 14, E(or <br /> PropZ 4D S. ICA LK 90-ertyOwner's Mailing Address Lot Number, Block Number <br /> !+� <br /> City,State Zi Code Phone Number Subdivision Name or CSM Number <br /> AtJ 19 1( 1152254-717_0 o . V_ <br /> II. TYPE BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 2 Town OF ISC� A.R.PWW.4-MWAY <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 E] Apartment/Condo 02'$ so 61900 <br /> _`00 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. �4 New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5, ❑ Repair of an <br /> System System Tank Only---------------Existing System ___ ___ Existing System <br /> B) ❑ ASanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 1150 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 3O0 d 1000 , S q5.2 Feet 97. 7 Feet <br /> Capacil <br /> VII FORMATION in allons Total #of Manufacturer's Name Prefab. �o�_ Steel Fiber- plastic Exper <br /> New Existin G8110n5 Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 8o S00 I 59AW ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> IaN)qRp /-�oPK��1S t.Lltq,�t -3+2 IS- 866-457 <br /> Plumber's Address(Street,City,Stat ,Zip Code): <br /> Z'1 0 ;qw 3�5 Wgl;,TEK I <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved <br /> 1Sanitary Permit�1ndurcadescrovndwater ate Is ue [SSU A Sig ur amps) <br /> roved .Io <br /> Given Initial snargeree) G <br /> KJ Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD.6398(R.05N41) DISTRIBUTION: Original to Counly,One copy To: Safety&Ruildings Division,owner,Plumber <br />